The changes to Medicare quality reporting are here. Mingle Health is fully equipped with the knowledge, experience and tools you need to succeed with MACRA, MIPS and APMs.
Below are answers to common Quality Payment Program questions to help you better understand the coming changes in the way practices are evaluated.
2024 is the hardest year yet for MIPS and Medicare’s Quality Payment Program.
You must earn 75 points to avoid a penalty and negative payment adjustment. The maximum penalty remains at 9%.
Scroll down or use the navigation bar to the left for an overview of changes and what it takes to succeed in the Quality Payment Program.
The Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act, also known as MACRA, is legislation that brings the Centers for Medicare & Medicaid Services (CMS) one step closer to reimbursing healthcare providers based on the quality and cost of patient care rather than volume. The program starts in 2017 with the first penalties and incentives being paid in 2019.
MACRA, also known as the “doc fix” bill, repealed the flawed Sustainable Growth Rate (SGR) formula which was an earlier attempt to curb Medicare spending. Each year, the unwelcome cuts that would have been in effect by SGR were postponed by Congress and Medicare spending continued to grow.
In addition, the Physician Quality Reporting Program (PQRS), Value Modifier (VM) and Electronic Health Record Incentive Program (Meaningful Use or MU) were programs put in place that attempted to measure and control the quality and cost of healthcare.
The mix of PQRS, VM and MU created a complicated set of requirements including:
If MACRA was not enacted in 2015, there would have been a 21% cut in Medicare payments under SGR.
With MACRA, providers have more certainty of payments over the next 10 years and the annual fear of payment cuts will be alleviated. This new system aims to combine existing quality reporting programs under one unified program to streamline reporting.
MACRA repealed both the SGR and sunset PQRS, VM and MU programs, while instituting a new system: The Quality Payment Program (QPP). The QPP is the latest attempt to control cost and tie payment for services to the quality of care provided.
While there are multiple paths through the QPP, CMS expects most physicians will initially participate through the Merit-Based Incentive Payment System or MIPS.
Under MIPS, payments to providers are still based on the Medicare Part B Physician Fee Schedule (PFS) but those payments can be adjusted either up or down depending on their Final Score, which is made up of these four performance categories:
Based on their Final Score, providers have the potential to have their payments, under the PFS, adjusted by 9%, either positively or negatively. Additionally, positive adjustments can be influenced by two factors:
Despite the seemingly complex nature of MIPS, CMS has emphasized a desire to simplify and streamline the process for reporting quality data.
Under MIPS, the three categories that require submission of data (Quality, Promoting Interoperability and Improvement Activities) can be submitted through a single vendor. You may also mix and match submission data and group/individual submissions and CMS will credit you with whichever score is highest.
The common submission deadline is March 31 for MIPS. Some other programs have a slightly earlier reporting deadline, such as Primary Care First.
The Qualified Registry submission option has been the most reliable, flexible and cost-effective method for MIPS participation and submission.
Group Reporting continues to be a strong option for many because performance can be met via a visit with any provider in the group. If you elect to report as a group in the Quality Performance Category, you will report as a group for the remaining categories.
CMS does allow clinicians to report as part of a group AND submit data individually. Providers receive credit for whichever data scores the highest.
An industry leader in quality management and Medicare reporting, Mingle Health will help you avoid penalties and succeed with the Quality Payment Program.
Learn MoreUnder the QPP, providers can participate in an Alternative Payment Model, or APM, which are models that move further from the fee-for-service payment model to models that tie payment to value and focus on better care, smarter spending and healthier people.
Generally, providers band together to operate under an APM—Accountable Care Organizations are a popular example. CMS’ goal is to move more and more providers to participate in APMs.
One of the most exciting APMs is Primary Care First, a payment model that takes lessons from ACOs and CPC+ to increase payments to practices delivery advanced primary care to their patients.
Providers and organizations will receive additional points, within certain MIPS performance categories, for their participation in an APM.
Taking new payment models even further, Advanced APMs are payment models in which the organizations share the savings gained by delivering high-quality, low-cost care and often assume the down-side risk if the actual cost is higher than it would be under the PFS.
An Advanced APM requires participants to:
Examples of Advanced APMs include:
While most providers will be subject to MIPS, those who participate in Advanced APMs and are determined to be Qualifying Participants (QPs) are exempt from MIPS. They receive a 5% incentive and must measure both cost and quality along with other requirements of Advanced APM participation.
Clinicians participating in an Advanced APM are determined to be a QP if they meet the minimum threshold for the percentage of their patients or payments through an Advanced APM. The threshold is scheduled to increase through 2024.
If a provider or practice is not already in one of the CMS Advanced APMs or don’t meet the other requirements by one of the APM snapshot dates, they will file under MIPS. The “snapshot” dates are March 31, June 30 or August 31.
All APMs require an application to CMS. For some Advanced APMs, the deadline has passed depending on the time of year. CMS regularly announces opportunities to apply to increase participation. If someone is not under an Advanced APM contract, they will most likely be subject to MIPS.
It’s important to stay up-to-date with annual changes to the MIPS program. We know it’s challenging and that’s why everyone at Mingle Health is here to help.
Given that we’re exiting the transitional phase of the MIPS program, your past performance often provides insight into how you will perform in the current performance year.
The points you receive in the four, weighted performance categories make up your Final Score. Ultimately, how your Final Score compares to the threshold score set by CMS each year will determine whether you receive an incentive or penalty. In the first year of MIPS, each performance category is weighted as follows:
The threshold to avoid the penalty is now 75 points.
Your Final Score is the aggregate of the weighted score in each category. Each year, the Final Score threshold will be set prior to the program year and will be based on comparative scores across all MIPS-eligible practices. Providers scoring above the threshold will receive a positive adjustment and those scoring below the threshold will receive a negative adjustment.
The adjustments will be “budget neutral” so the dollars produced on the negative side will be distributed among practices on the positive side. There is also an opportunity to earn additional points for extraordinary performance.
Weight of Performance Category Changes by Year
Accounting for 60% of your Final Score for 2017, this category aims to prioritize and reward providers for the quality of their patient care based on evidenced-based measures.
The Quality category has two sets of measures:
CMS-Calculated Measures
In 2017, CMS will use just one measure to contribute to your Quality Score: All-cause Hospital Readmissions (ACR). In the future, CMS-calculated measures may include scores for Acute Conditions Composite and Chronic Conditions Composite. The Acute Conditions Composite is made up of scores related to hospital admissions for bacterial pneumonia, urinary tract infections and dehydration. The Chronic Conditions Composite score is made up of diabetes, chronic obstructive pulmonary disease or asthma and heart failure.
Measures Submitted by Providers
The quality measures submitted by providers replace the Physician Quality Reporting System (PQRS), which required clinicians to report on nine measures across three domains. Under MIPS, providers only need to report on six measures, including one outcome measure. If an outcome measure isn’t available, selecting another high priority measure is an option.
There will be more than 200 measures to choose from, with 80% being tailored toward specialists who often have a difficult time when it comes to finding suitable measures. CMS has developed a series of specialty measure sets to further help providers select ones that are meaningful and within their scope of practice.
PQRS Measure Groups, with their requirement to report on just 20 patients, is no longer an option.
In 2017, the performance period is just 90 days to earn an incentive. The performance period will increase in future years of MIPS. To prepare for more rigorous reporting requirements, CMS strongly encourages practices to report for a full year, but a full year of data will not increase the incentive.
For Registry reporting in 2017, you must report on patients from all payers that are eligible for the measure, not just patients with Medicare Part B insurance. In future years, the completeness criteria for Registry reporting will increase to a full year of data for 90% of all eligible patients that meet the denominator criteria for the measure for all payers.
The score on the measures will be compared to national benchmarks and each measure will receive 0-10 points within this performance category based on which decile they fall into relative to the benchmark.
For the CMS-calculated measures, similar to the score for Resource Use, focusing on taking good care of patients with chronic conditions and treating acute conditions early to avoid hospitalizations will be your best approach to influencing this score.
For the measures you submit—just as under the Value Modifier (VM)—choosing the right measures to report has become extremely important, because now performance counts.
A HELPFUL TIP
For both the CMS-calculated measures and the submitted measures, take a look at your Quality and Resource Use Reports (QRUR) as far back as you are able. Do you find your scores to be at or below benchmark?
While no guarantee, past performance is the best indicator of future performance, unless you radically change how you take care of patients. If your score is below benchmark in any section, look closely at those areas of practice that influence that score.
In 2017, this performance category accounts for 15% of your Final Score.
Under this new category, MIPS rewards practices that are focused on improvement efforts such as:
The CPIA category also provides credits for a clinician’s participation in APMs and Patient-Centered Medical Homes. There are currently 91 activities proposed which physicians may choose from. The activities are applicable across all specialties and achievable for small practices and those in remote locations.
Some activities carry more points than others and in the Transition Year, you need just 40 points to get “full credit” for this category. If you have Patient-Centered Medical Home recognition or certification, you will receive full credit automatically.
Review the list of 91 clinical practice improvement activities that you can get
points for under this new performance category.
Look for the things you may be doing already that would earn points. You must demonstrate you are doing them for at least 90 days to get credit for the activity. Start planning now to see what you can implement. There are measures that will also earn “bonus” points in ACI.
CPIAs can be anything from a program you already have in place for timely communication of test results, participation in a Practice Transformation Network (PTN) or Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS).
Representing 25% of your Final Score, the Advancing Care Information (ACI) performance category replaces the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals—also known as Meaningful Use (MU).
This performance category eliminates the confusion generated by the overlap in quality reporting for the PQRS and MU program for eligible professionals. The ACI eliminates the MU requirements to report Clinical Quality Measures (CQMs). Instead, under MIPS, all quality measures will be reported through the Quality performance category. However, MIPS ACI does not remove the Hospital or Medicaid EHR Incentive programs. Providers who are enrolled in the Medicaid and Hospital MU programs will continue in those programs and in MIPS ACI, if MIPS applies to them.
The Final Rule has decreased the number of required ACI measures from 11 to 5:
There are two parts to scoring in this category: a base score and a performance score. For the base scoring on the five measures, you must use the EHR technology for at least one patient for each measure. If you do not meet the five base measures with either a “Yes” or a “1” in the numerator, you will fail in this performance category. A base score on the five measures in this category (along with requirements in other categories) is all that is required to earn an incentive in this first year of MIPS.
If you do meet the base score for the performance score, you will earn points for each measure depending on the number of patients for whom you use the EHR technology.
These categories each contain additional measures that you can use to boost your performance score, including:
There are also bonus points for reporting to an Immunization Registry, other Public Health and Clinical Data Registries and for improvement activities that use Certified EHR Technology (CEHRT).
Under certain conditions, certain groups of providers do not need to report for this category. The points for this category will be reallocated to other performance categories.
Measure Example: Patent-Generated Health Data
The base score for the Coordination of Care Through Patient Engagement objective for the measure Patient-Generated Health Data requires that you have at least one patient for which you incorporate health data into the EHR.
The performance score for this measure uses the number of unique patients seen by the MIPS-eligible clinician during the performance period as a denominator. The numerator is the number of patients in the denominator for whom data from nonclinical settings—which may include Patient-Generated Health Data—is captured through the certified EHR technology into the patient record during the performance period.
Make sure you are on track to be using EHR technology that is at least the 2014 edition and successfully attest to MU in 2016.
The score in this category is calculated based on Medicare claims data, meaning there is no data you need to submit.
Even though your Resource Use score will not count in 2017, it will count in future years of MIPS and it’s still important to understand how your score is calculated. Resource Use is scheduled to be 30% by 2019.
In this category, CMS examines the claims data to determine the cost of caring for patients attributed to the practice. Patients are attributed to a practice they visit most often for primary care services. Though Resource Use will not factor into the Final Score for 2017, CMS will continue to provide data on Medicare Spending Per Beneficiary (MSPB), total per capita costs for all attributed beneficiaries and costs for ten episode-based measures.
Performance will be influenced not just by charges originating from the group of providers being evaluated, but by other providers who see the same patients.
To succeed in this performance category, the goal is to keep patients coming back to your practice.
When they look to you for their care, you have better control of who else they see and can make thoughtful choices about referrals to clinical partners who share your approach and are mindful of controlling cost and providing good care.
Adopting the philosophy and practice of a Patient-Centered Medical Home will go a long way to succeed in controlling Resource Use. A Patient-Centered Medical Home keeps patients coming back to you so you provide care when they need it, thereby preventing costly visits to emergency departments. Good tracking and treatment for patients with chronic conditions will also prevent expensive hospitalizations that contribute to the overall cost of care.
If you are a physician (MD/DO and DMD/DDS), PA, NP, clinical nurse specialist or a certified registered nurse anesthetist and not participating in an Advanced APM, MIPS most likely applies to you in the first year.
It does not apply to you if you meet one of the following criteria:
In order to achieve a successful Final Score so that your practice gets the highest reimbursement possible, here is what you can do to prepare:
1. Educate your practice on the Quality Payment Program now.
You may want to assign one staff member with the responsibility of tracking and managing the necessary reports and your EHR system. Share our recorded webinars on the QPP with them.
2. Make sure your EHR is certified to the 2014 edition or later.
Your Advancing Care Information score will be dependent on this and you’ll earn additional points in other categories.
3. Select a reporting partner and participate in PQRS in 2016.
Begin building your relationship with a vendor who can report for you in 2016 and on into MIPS for 2017. Learn the measures and choose ones where you can exceed benchmarks. You should look at opportunities to improve starting now.
4. Estimate your MIPS score.
Use your Quality and Resource Use Report (QRUR) and Meaningful Use (MU) reports to see where you fall when comparing cost and quality.
5. Look for opportunities to implement clinical practice improvement activities.
Start planning now to see what you can implement. You must demonstrate you are doing them for at least 90 days to get credit for the activity. You may already be doing things that would earn you points.
6. Identify deadlines and timetables.
Unlike filing your taxes, for MIPS reporting there is no extension. Not reporting will incur an automatic penalty.
7. Stay informed.
Follow our blog for up-to-date information and review our webinars. We hold frequent tutorials and post articles discussing the latest changes and requirements when it comes to Medicare so you’re always in the loop.
8. Keep providing high quality care!
MACRA was created to prioritize and reward better patient care, smarter spending and healthier patients, so keep being the best healthcare provider you can be!
We hope this overview of MACRA, MIPS and APMs made the new Medicare reporting process a little easier to understand. It’s a complicated system, but using our keys to succeed should help ease the burden and give you a head start for next year!
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MIPS Solutions by Mingle Health empowers you with expert consultants and cutting-edge tools to succeed with the new Quality Payment Program. Learn more
